The commentary provided by the primary author of this report suggests that there is a need for reappraisal of opioid use in chronic, non-cancer pain. The pendulum may have swung from “opiophobia” in the 1950’s to today’s apparent “opiophilia”. However, while some patients are on very high doses of opioids with little or questionable benefit, there are a greater number of patients who have not been prescribed any opioids despite serious physical pathology.
There seems to be many problems with opioid prescribing-overuse, abuse, misuse, diversion, underuse and opioid over-prescribing.
Since providers have been prescribing opioids for chronic, non-cancer pain, the Drug Abuse Warning Network has documented a seven-fold increase in Emergency Department visits and overdose deaths related to oxycodone alone. Other studies have shown that the rate of prescription opioid abuse has exceeded the rate of heroin use.
While opioids may be quite useful for moderate to severe pain, the mean decrease in pain intensity in most studies is 30 per cent.
Physicians have to navigate between the extremes of no prescribing versus excessive prescribing by prescribing opioids when indicated. They must learn to identify and manage opioid misuse and addiction, and avoid prescribing excessive doses.
In general, opioids are not considered to have a dose range and ceiling. It is also believed that high doses can be safely titrated. These commonly held beliefs are only partially supported by evidence. The analgesic effects of high opioid doses are limited by the development of hyperalgesia and analgesic tolerance. Cognitive impairment is another concern but the authors concluded that studies have not been adequate.
Abuse-deterrent formulations may be key in the control of prescription opioid abuse. They make it more difficult or impossible for patients to extract the opioid by crushing, biting, snorting or injecting it. This will reduce the risk of addiction and street value of opioids. Their utility will be influenced by cost, availability, and acceptance by physicians and patients. Perhaps their greatest value is that they will reassure physicians and the public that opioids can be prescribed safely without undue fear of addiction.